Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

99285 Visit Level 5 ED PRO FEE

Facility

$1,896.00

Service Code	CPT 99285
Hospital Charge Code	5175397
Min. Negotiated Rate	$300.33
Max. Negotiated Rate	$1,909.00
Rate for Payer: Aetna of AZ Commercial	$1,706.40
Rate for Payer: Arizona Complete Health Allwell	$303.36
Rate for Payer: Banner UC Health Medicare	$303.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,289.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$303.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$303.36
Rate for Payer: Cash Price	$1,516.80
Rate for Payer: Cash Price	$1,516.80
Rate for Payer: Cash Price	$1,516.80
Rate for Payer: Cigna of AZ Commercial	$1,327.20
Rate for Payer: Devoted Health Medicare	$341.28
Rate for Payer: Humana of AZ Medicare	$303.36
Rate for Payer: Seven Corners Travel Insurance	$921.45
Rate for Payer: Southwest Service Administrators UFCW	$1,289.28
Rate for Payer: TriWest Medicare	$303.36
Rate for Payer: United Healthcare Commercial	$1,909.00
Rate for Payer: United Healthcare Medicare	$303.36
Rate for Payer: Veterans Affairs TRICARE	$300.33

99291 - ED Critical Care

Facility

$3,576.00

Service Code	CPT 99291
Hospital Charge Code	22283180
Hospital Revenue Code	450
Min. Negotiated Rate	$53.55
Max. Negotiated Rate	$3,218.40
Rate for Payer: Aetna of AZ Commercial	$3,218.40
Rate for Payer: Arizona Complete Health Allwell	$572.16
Rate for Payer: Banner UC Health Medicare	$572.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,431.68
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$53.55
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$572.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$572.16
Rate for Payer: Cash Price	$2,860.80
Rate for Payer: Cash Price	$2,860.80
Rate for Payer: Cash Price	$2,860.80
Rate for Payer: Cigna of AZ Commercial	$2,503.20
Rate for Payer: Devoted Health Medicare	$643.68
Rate for Payer: Humana of AZ Medicare	$572.16
Rate for Payer: Mercy Care Medicaid	$53.55
Rate for Payer: NaphCare Correctional Healthcare	$53.55
Rate for Payer: Seven Corners Travel Insurance	$1,278.09
Rate for Payer: Southwest Service Administrators UFCW	$2,431.68
Rate for Payer: TriWest Medicare	$572.16
Rate for Payer: United Healthcare Commercial	$2,780.00
Rate for Payer: United Healthcare Medicare	$572.16
Rate for Payer: United Healthcare New Mexico Commercial	$679.44
Rate for Payer: Veterans Affairs TRICARE	$566.44

99291 - ED Critical Care

Facility

$3,576.00

Service Code	CPT 99291
Hospital Charge Code	22283180
Hospital Revenue Code	450
Min. Negotiated Rate	$3,218.40
Max. Negotiated Rate	$3,218.40
Rate for Payer: Aetna of AZ Commercial	$3,218.40
Rate for Payer: Cash Price	$2,860.80

99292 Critical care, evaluation and management of the critic

Facility

$210.00

Service Code	CPT 99292
Hospital Charge Code	24767656
Hospital Revenue Code	982
Min. Negotiated Rate	$11.31
Max. Negotiated Rate	$189.00
Rate for Payer: Aetna of AZ Commercial	$189.00
Rate for Payer: Arizona Complete Health Allwell	$33.60
Rate for Payer: Banner UC Health Medicare	$33.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$142.80
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$11.31
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$33.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$33.60
Rate for Payer: Cash Price	$168.00
Rate for Payer: Cash Price	$168.00
Rate for Payer: Cigna of AZ Commercial	$147.00
Rate for Payer: Devoted Health Medicare	$37.80
Rate for Payer: Humana of AZ Medicare	$33.60
Rate for Payer: Mercy Care Medicaid	$11.31
Rate for Payer: NaphCare Correctional Healthcare	$11.31
Rate for Payer: Southwest Service Administrators UFCW	$142.80
Rate for Payer: TriWest Medicare	$33.60
Rate for Payer: United Healthcare Commercial	$120.12
Rate for Payer: United Healthcare Medicare	$33.60
Rate for Payer: United Healthcare New Mexico Commercial	$39.90
Rate for Payer: Veterans Affairs TRICARE	$33.26

99292 Critical care, evaluation and management of the critic

Facility

$210.00

Service Code	CPT 99292
Hospital Charge Code	24767656
Hospital Revenue Code	982
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$189.00
Rate for Payer: Aetna of AZ Commercial	$189.00
Rate for Payer: Cash Price	$168.00

99292 - ED Critical Care, each 30 min

Facility

$1,822.00

Service Code	CPT 99292
Hospital Charge Code	22283181
Hospital Revenue Code	450
Min. Negotiated Rate	$1,639.80
Max. Negotiated Rate	$1,639.80
Rate for Payer: Aetna of AZ Commercial	$1,639.80
Rate for Payer: Cash Price	$1,457.60

99292 - ED Critical Care, each 30 min

Facility

$1,822.00

Service Code	CPT 99292
Hospital Charge Code	22283181
Hospital Revenue Code	450
Min. Negotiated Rate	$11.31
Max. Negotiated Rate	$1,639.80
Rate for Payer: Aetna of AZ Commercial	$1,639.80
Rate for Payer: Arizona Complete Health Allwell	$291.52
Rate for Payer: Banner UC Health Medicare	$291.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,238.96
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$11.31
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$291.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$291.52
Rate for Payer: Cash Price	$1,457.60
Rate for Payer: Cash Price	$1,457.60
Rate for Payer: Cigna of AZ Commercial	$1,275.40
Rate for Payer: Devoted Health Medicare	$327.96
Rate for Payer: Humana of AZ Medicare	$291.52
Rate for Payer: Mercy Care Medicaid	$11.31
Rate for Payer: NaphCare Correctional Healthcare	$11.31
Rate for Payer: Southwest Service Administrators UFCW	$1,238.96
Rate for Payer: TriWest Medicare	$291.52
Rate for Payer: United Healthcare Commercial	$1,042.18
Rate for Payer: United Healthcare Medicare	$291.52
Rate for Payer: United Healthcare New Mexico Commercial	$346.18
Rate for Payer: Veterans Affairs TRICARE	$288.60

99304 SWING BED INITIAL LOW COMPLEX

Facility

$162.00

Service Code	CPT 99304
Hospital Charge Code	22361556
Hospital Revenue Code	524
Min. Negotiated Rate	$145.80
Max. Negotiated Rate	$145.80
Rate for Payer: Aetna of AZ Commercial	$145.80
Rate for Payer: Cash Price	$129.60

99304 SWING BED INITIAL LOW COMPLEX

Facility

$162.00

Service Code	CPT 99304
Hospital Charge Code	22361556
Hospital Revenue Code	524
Min. Negotiated Rate	$25.66
Max. Negotiated Rate	$145.80
Rate for Payer: Aetna of AZ Commercial	$145.80
Rate for Payer: Arizona Complete Health Allwell	$25.92
Rate for Payer: Banner UC Health Medicare	$25.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$110.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$25.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$25.92
Rate for Payer: Cash Price	$129.60
Rate for Payer: Cigna of AZ Commercial	$113.40
Rate for Payer: Devoted Health Medicare	$29.16
Rate for Payer: Humana of AZ Medicare	$25.92
Rate for Payer: Southwest Service Administrators UFCW	$110.16
Rate for Payer: TriWest Medicare	$25.92
Rate for Payer: United Healthcare Commercial	$92.66
Rate for Payer: United Healthcare Medicare	$25.92
Rate for Payer: Veterans Affairs TRICARE	$25.66

99305 SWING BED INITIAL MODERATE COMPLEX

Facility

$654.00

Service Code	CPT 99305
Hospital Charge Code	22361557
Hospital Revenue Code	524
Min. Negotiated Rate	$588.60
Max. Negotiated Rate	$588.60
Rate for Payer: Aetna of AZ Commercial	$588.60
Rate for Payer: Cash Price	$523.20

99305 SWING BED INITIAL MODERATE COMPLEX

Facility

$654.00

Service Code	CPT 99305
Hospital Charge Code	22361557
Hospital Revenue Code	524
Min. Negotiated Rate	$103.59
Max. Negotiated Rate	$588.60
Rate for Payer: Aetna of AZ Commercial	$588.60
Rate for Payer: Arizona Complete Health Allwell	$104.64
Rate for Payer: Banner UC Health Medicare	$104.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$444.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$104.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$104.64
Rate for Payer: Cash Price	$523.20
Rate for Payer: Cigna of AZ Commercial	$457.80
Rate for Payer: Devoted Health Medicare	$117.72
Rate for Payer: Humana of AZ Medicare	$104.64
Rate for Payer: Southwest Service Administrators UFCW	$444.72
Rate for Payer: TriWest Medicare	$104.64
Rate for Payer: United Healthcare Commercial	$374.09
Rate for Payer: United Healthcare Medicare	$104.64
Rate for Payer: Veterans Affairs TRICARE	$103.59

99306 SWING BED INITIAL COMPREHENSIVE

Facility

$977.00

Service Code	CPT 99306
Hospital Charge Code	22361558
Min. Negotiated Rate	$879.30
Max. Negotiated Rate	$879.30
Rate for Payer: Aetna of AZ Commercial	$879.30
Rate for Payer: Cash Price	$781.60

99306 SWING BED INITIAL COMPREHENSIVE

Facility

$977.00

Service Code	CPT 99306
Hospital Charge Code	22361558
Min. Negotiated Rate	$154.76
Max. Negotiated Rate	$879.30
Rate for Payer: Aetna of AZ Commercial	$879.30
Rate for Payer: Arizona Complete Health Allwell	$156.32
Rate for Payer: Banner UC Health Medicare	$156.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$664.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$156.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$156.32
Rate for Payer: Cash Price	$781.60
Rate for Payer: Cigna of AZ Commercial	$683.90
Rate for Payer: Devoted Health Medicare	$175.86
Rate for Payer: Humana of AZ Medicare	$156.32
Rate for Payer: Southwest Service Administrators UFCW	$664.36
Rate for Payer: TriWest Medicare	$156.32
Rate for Payer: United Healthcare Commercial	$558.84
Rate for Payer: United Healthcare Medicare	$156.32
Rate for Payer: Veterans Affairs TRICARE	$154.76

99307 SWINGBED SUBSEQUENT FOCUSED

Facility

$260.00

Service Code	CPT 99307
Hospital Charge Code	22361559
Hospital Revenue Code	524
Min. Negotiated Rate	$234.00
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna of AZ Commercial	$234.00
Rate for Payer: Cash Price	$208.00

99307 SWINGBED SUBSEQUENT FOCUSED

Facility

$260.00

Service Code	CPT 99307
Hospital Charge Code	22361559
Hospital Revenue Code	524
Min. Negotiated Rate	$41.18
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna of AZ Commercial	$234.00
Rate for Payer: Arizona Complete Health Allwell	$41.60
Rate for Payer: Banner UC Health Medicare	$41.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$176.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$41.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$41.60
Rate for Payer: Cash Price	$208.00
Rate for Payer: Cigna of AZ Commercial	$182.00
Rate for Payer: Devoted Health Medicare	$46.80
Rate for Payer: Humana of AZ Medicare	$41.60
Rate for Payer: Southwest Service Administrators UFCW	$176.80
Rate for Payer: TriWest Medicare	$41.60
Rate for Payer: United Healthcare Commercial	$148.72
Rate for Payer: United Healthcare Medicare	$41.60
Rate for Payer: Veterans Affairs TRICARE	$41.18

99308 SWINGBED SUBSEQUENT EXPANDED

Facility

$401.00

Service Code	CPT 99308
Hospital Charge Code	22361560
Hospital Revenue Code	524
Min. Negotiated Rate	$63.52
Max. Negotiated Rate	$360.90
Rate for Payer: Aetna of AZ Commercial	$360.90
Rate for Payer: Arizona Complete Health Allwell	$64.16
Rate for Payer: Banner UC Health Medicare	$64.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$272.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$64.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$64.16
Rate for Payer: Cash Price	$320.80
Rate for Payer: Cigna of AZ Commercial	$280.70
Rate for Payer: Devoted Health Medicare	$72.18
Rate for Payer: Humana of AZ Medicare	$64.16
Rate for Payer: Southwest Service Administrators UFCW	$272.68
Rate for Payer: TriWest Medicare	$64.16
Rate for Payer: United Healthcare Commercial	$229.37
Rate for Payer: United Healthcare Medicare	$64.16
Rate for Payer: Veterans Affairs TRICARE	$63.52

99308 SWINGBED SUBSEQUENT EXPANDED

Facility

$401.00

Service Code	CPT 99308
Hospital Charge Code	22361560
Hospital Revenue Code	524
Min. Negotiated Rate	$360.90
Max. Negotiated Rate	$360.90
Rate for Payer: Aetna of AZ Commercial	$360.90
Rate for Payer: Cash Price	$320.80

99309 SWINGBED SUBSEQUENT DETAILED

Facility

$529.00

Service Code	CPT 99309
Hospital Charge Code	22361561
Hospital Revenue Code	524
Min. Negotiated Rate	$83.79
Max. Negotiated Rate	$476.10
Rate for Payer: Aetna of AZ Commercial	$476.10
Rate for Payer: Arizona Complete Health Allwell	$84.64
Rate for Payer: Banner UC Health Medicare	$84.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$359.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$84.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$84.64
Rate for Payer: Cash Price	$423.20
Rate for Payer: Cigna of AZ Commercial	$370.30
Rate for Payer: Devoted Health Medicare	$95.22
Rate for Payer: Humana of AZ Medicare	$84.64
Rate for Payer: Southwest Service Administrators UFCW	$359.72
Rate for Payer: TriWest Medicare	$84.64
Rate for Payer: United Healthcare Commercial	$302.59
Rate for Payer: United Healthcare Medicare	$84.64
Rate for Payer: Veterans Affairs TRICARE	$83.79

99309 SWINGBED SUBSEQUENT DETAILED

Facility

$529.00

Service Code	CPT 99309
Hospital Charge Code	22361561
Hospital Revenue Code	524
Min. Negotiated Rate	$476.10
Max. Negotiated Rate	$476.10
Rate for Payer: Aetna of AZ Commercial	$476.10
Rate for Payer: Cash Price	$423.20

99310 SWINGBED SUBSEQUENT COMPREHENSIVE

Facility

$375.00

Service Code	CPT 99310
Hospital Charge Code	22361562
Min. Negotiated Rate	$337.50
Max. Negotiated Rate	$337.50
Rate for Payer: Aetna of AZ Commercial	$337.50
Rate for Payer: Cash Price	$300.00

99310 SWINGBED SUBSEQUENT COMPREHENSIVE

Facility

$375.00

Service Code	CPT 99310
Hospital Charge Code	22361562
Min. Negotiated Rate	$59.40
Max. Negotiated Rate	$337.50
Rate for Payer: Aetna of AZ Commercial	$337.50
Rate for Payer: Arizona Complete Health Allwell	$60.00
Rate for Payer: Banner UC Health Medicare	$60.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$255.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$60.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$60.00
Rate for Payer: Cash Price	$300.00
Rate for Payer: Cigna of AZ Commercial	$262.50
Rate for Payer: Devoted Health Medicare	$67.50
Rate for Payer: Humana of AZ Medicare	$60.00
Rate for Payer: Southwest Service Administrators UFCW	$255.00
Rate for Payer: TriWest Medicare	$60.00
Rate for Payer: United Healthcare Commercial	$214.50
Rate for Payer: United Healthcare Medicare	$60.00
Rate for Payer: Veterans Affairs TRICARE	$59.40

99316 SWINGBED DISCHARGE >30 MINUTES

Facility

$293.00

Service Code	CPT 99316
Hospital Charge Code	22361564
Min. Negotiated Rate	$263.70
Max. Negotiated Rate	$263.70
Rate for Payer: Aetna of AZ Commercial	$263.70
Rate for Payer: Cash Price	$234.40

99316 SWINGBED DISCHARGE >30 MINUTES

Facility

$293.00

Service Code	CPT 99316
Hospital Charge Code	22361564
Min. Negotiated Rate	$46.41
Max. Negotiated Rate	$263.70
Rate for Payer: Aetna of AZ Commercial	$263.70
Rate for Payer: Arizona Complete Health Allwell	$46.88
Rate for Payer: Banner UC Health Medicare	$46.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$199.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$46.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$46.88
Rate for Payer: Cash Price	$234.40
Rate for Payer: Cigna of AZ Commercial	$205.10
Rate for Payer: Devoted Health Medicare	$52.74
Rate for Payer: Humana of AZ Medicare	$46.88
Rate for Payer: Southwest Service Administrators UFCW	$199.24
Rate for Payer: TriWest Medicare	$46.88
Rate for Payer: United Healthcare Commercial	$167.60
Rate for Payer: United Healthcare Medicare	$46.88
Rate for Payer: Veterans Affairs TRICARE	$46.41

99360 PHYSICIAN STANDBY EACH 30 MIN CRITICAL C

Facility

$194.00

Service Code	CPT 99360
Hospital Charge Code	22282746
Min. Negotiated Rate	$30.73
Max. Negotiated Rate	$174.60
Rate for Payer: Aetna of AZ Commercial	$174.60
Rate for Payer: Arizona Complete Health Allwell	$31.04
Rate for Payer: Banner UC Health Medicare	$31.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$131.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$31.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$31.04
Rate for Payer: Cash Price	$155.20
Rate for Payer: Cigna of AZ Commercial	$135.80
Rate for Payer: Devoted Health Medicare	$34.92
Rate for Payer: Humana of AZ Medicare	$31.04
Rate for Payer: Southwest Service Administrators UFCW	$131.92
Rate for Payer: TriWest Medicare	$31.04
Rate for Payer: United Healthcare Commercial	$110.97
Rate for Payer: United Healthcare Medicare	$31.04
Rate for Payer: Veterans Affairs TRICARE	$30.73

99360 PHYSICIAN STANDBY EACH 30 MIN CRITICAL C

Facility

$194.00

Service Code	CPT 99360
Hospital Charge Code	22282746
Min. Negotiated Rate	$174.60
Max. Negotiated Rate	$174.60
Rate for Payer: Aetna of AZ Commercial	$174.60
Rate for Payer: Cash Price	$155.20

Know your out-of-pocket cost for care.

All Charges